MEDICARE: ROCKY CREEK YOUTH RANCH INCORPORTATED

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility	N000701465	MO

General Provider Information

NPI Number	:	1790148971
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROCKY CREEK YOUTH RANCH INCORPORTATED

Provider Business Mailing Address
First Line	:	1286 MATTHEWS LN
Second Line	:
City	:	PARK HILLS
State	:	MO
Zip	:	63601-7207
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1286 MATTHEWS LN
Second Line	:
City	:	PARK HILLS
State	:	MO
Zip	:	63601-7207
Country	:	US
Telephone Number	:	573-562-7751
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	CLIFF TALLEY
Credential	:
Telephone Number	:	573-562-7751

Provider Enumeration Date	:	04/04/2016
Last Update Date	:	04/04/2016

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